N.

202-INTRODUCTION TO NURSING PRACTICE

HEALTH ASSESSMENT TOOL
[1]
Patient's name (Initials only) ____HK______ Bed number ___77____
Assessor: __Monira Huseino Vitch________ Interview date: ___13/08/2020____
Source of Information (Specify): __Patient______ Reliability : Good Fair Poor.
Birth Date: _12/07/1990_____ Age: __30_ Gender: M. F. Marital Status: S M W D.
If married, years married ______ Number of children _______
Highest level of education: _university_____ Occupation: ______school teacher_____
Admission Date: _____13/08/2020__________ Admitted from: ____ER_______
Medical Diagnosis: ___________depression and bradycardia______________________
Address: _____________Dawra_______ Lives: Alone With:_____________________
Health insurance: Yes No.
Past Medical History:__________ none (NA)___________________________________________
Past Surgical
History:________none______________________________________________________

CHIEF COMPLAINT(S):[2]
__having shortness of breaths, feeling of fatigue, sometimes feels dizzy when waking up in the
morning daily.
Feeling extremely sad and worthless most of the time, and not going out anymore to see his friends
every Saturday as usual and it's been this way for 6 months.
REASON FOR ADMISSION:[2]
Feeling low and sad most of the time with feelings of fatigue and dull pain, it began 6 months ago,
dull pain in the chest area, it doesn’t radiate, it lasts 1 hour in the morning and another hour before
sleep, every time pain increases his sad feelings and brings him more fatigue; Takes painkillers to ease
the pain and tiredness.
Nursing diagnosis
HEALTH PERCEPTION AND MANAGEMENT [1]
Regular physical check ups: Yes No.
Smoker: Yes  No. If yes, packs/day: _____ Number of years _________ Altered health maintenance
Narjileh use: Yes No. If yes, frequency of use/week_______________
Alcohol use: Yes No. If yes, frequency/week_______ Amount:______
Other drugs: Yes No. If yes, type, frequency, amount: _____________
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SAFETY AND PROTECTION: [1]

Allergies (food, drug, dye, other) ____NA_______ Reaction: __NA___________ Risk for suffocation
Impaired vision/hearing: Yes No. Mental disability ____NA________ Risk for poisoning
Ambulatory devices __NA___ Deformities _NA___ Prosthesis _NA____ Risk for injury
Blood transfusions: Yes No. If yes, date: _______ Reaction: _______
MOVING Nursing diagnosis
Subjective [1]
Exercise habits (type, frequency) _________a jog once a week_______ Impaired physical mobility
Limitation(s) in mobility (Specify): _________NA___________________ *(Walking, bed mobility,
Fatigue weakness pain dyspnea ____________________________ * transferability)
Sleep: Hours: __6 hours____ Naps: __NA____ Aids: ______NA_______ Fatigue
Difficulty falling/remaining asleep: ___yes especially after a stressful day___ Sleep pattern
disturbance
Objective:[1]
Response to activity: At rest After activity (Risk for) activity intolerance
a- Cardiovascular: HR _____50___ __65_______
b- Respiratory: RR _______10____ ____18_____
Type of activity: _______jogging_______ Other response:__NA________
Muscle mass/tone/strength: Emaciation Flaccidity Rigidity
Paralysis. Posture: __upright_____ Gait: __correct_______
Range of Motion: Full Other:______________________
Fracture/dislocations: __NA _____ Joint problems: ____NA____
Back problems:_______NA______ Other: __NA_____________
Activities of daily living:
Subjective:[1]
Independent. Dependent (check what applies to your client):
Mobility Feeding Hygiene Dressing/grooming Toileting Impaired mobility Other
(Specify): ______NA_____________________________________ Feeding self care deficit
Objective:[1] Bathing/hygiene self care deficit
Body odor: ___fresh and clean _ Presence of vermin: Yes No Dressing/grooming self care deficit
Toileting self care deficit
SYSTEMS
I- Cardiovascular
Subjective:[2]
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History of: Hypertension: ___NA_____ Heart disease: NA______ Altered tissue perfusion:
Rheumatic Fever: ___NA__ Ankle/leg edema: _NA___ *Cardiopulmonary
Phlebitis: ___NA_________ *Peripheral
Numbness/Tingling (location):_____NA________
Chest pain (Describe):dull and is felt everyday with the slow heart rate Altered comfort related to chest
pain
Objective:[2]
BP: Rt: __122/78 mmHg_Lt:_124/79 mmHg_ Position: Lying sitting standing.
Pulse pressure: ___44__________ Nursing diagnosis
Pulses (palpation): Carotid: _50__Temporal: 50__ Brachial: _50_ Radial: 50___
Femoral: _50_ Popliteal: _50_ Posttibial _50__Dorsalis Pedis: _50___
Heart sounds: _bradycardia _______________________
Heart rate: _50 Rhythm:  Regular Irregular. Quality: Strong Weak
Jugular vein distention: Yes No. Position: Lying Sitting.
Extremities: Skin temperature: Warm Cold. Capillary refill: __3.5 seconds ____
Homan's sign: Yes No. Varicosities: ______NA________________
Edema(specify): General Dependent Ascites (Risk for) Fluid volume excess
Skin: Pallor: Overall Lips Nailbeds Conjunctiva
Skin: cyanosis: Overall Lips Nailbeds Conjunctiva
II- Oxygenation:
Subjective:[2]
Dyspnea/Orthopnea (Describe): _____NA_________________________
Cough: Productive Nonproductive. Hemoptysis: Yes No
History of: Bronchitis: ___NA____________ Asthma: __NA_____________
Tuberculosis: _____NA________ Emphysema: _NA___________
Use of respiratory aids: ____NA__________Oxygen: ___NA__________
Objective:[2]
Respirations: Rate: 10 Depth: short expansion Rhythm: regular & spontaneous
Ineffective breathing pattern
Quality: Labored Unlabored. Chest expansion: _equal bilateral _(but short expansion)__________.
Accessory muscles use: Yes No. Pursed lip breathing: Yes No
Breath sounds:
Rt upper lobe: Normal Decreased Abnormal ___________________
Lt upper lobe:Normal Decreased Abnormal ____________________
Rt lower lobe: Normal Decreased Abnormal ___________________
Lt lower lobe: Normal Decreased Abnormal ___________________
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Sputum: Color: __NA __ Amount:__NA______ Consistency: Thick Thin Ineffective airway

clearance
Use of incentive spirometer: Yes No. Clubbing of fingers: Yes No
III-Nutrition
Subjective:[2]
Type of diet: At home: 2meals a day__Current _3 meals__________ Altered nutrition (Risk for):
Food intolerance: Yes No. If yes, describe______________________ *Less than body requirement
Appetite changes: Yes No. If yes, describe when feeling down and sad he skips meals
*More than body requirement
Nausea/vomiting: Yes No. If yes, describe______________________ Nursing Diagnosis
History of: ulcers Heart burn Indigestion: ____NA_____________ Altered oral mucous membranes
Dentures: Upper Lower. Mastication problems: Yes No. Altered dentition
Swallowing problems: __________No_______________ Impaired swallowing
Usual weight: ___80__ Changes in weight ( or ): ____decrease_____ Risk for aspiration
History of Diabetes mellitus: ___________________No__________
Objective:[2]
Current weight: _75__ Height: __183___ Body mass index:_22.4_____
Hernia/masses: Yes No. If yes, location/size:_________________
Thyroid enlarged: Yes No. Halitosis: Yes No
Condition of teeth/gums/tongue/mucous membranes: clean teeth, pink& firm gums and tongue, pink
& moist mucous membranes
IV therapy: ______________________________________________
IV-Elimination:
- Gastrointestinal/bowel
Subjective:[2]
Usual bowel patterns: Frequency__1_ Color/consistency: light brown, soft Constipation (Risk
for)
Diarrhea Constipation Incontinence. Stoma/ostomy:Yes No. Diarrhea
Remedies used for bowel problems: ______none_______________ Bowel incontinence
History of bleeding: _______none_____ Hemorrhoids: _NA ______ Altered comfort
Objective:[2] Risk for fluid volume deficit
Bowel sounds (Describe):________gurgles& clicks___________________
Abdomen tender: Yes No. Soft Firm. Liver enlarged: Yes No
Palpable mass: Yes No. If yes, describe______________________
Hemorrhoids: (External): Yes No
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- Renal/urinary
Subjective:[2] (Risk for):
Usual urinary patterns: Times/day:__7__ Color: pale yellow Hematuria Altered urinary elimination
Incontinence Urgency Frequency Retention *Incontinence
Pain Burning Difficulty voiding Dribbling *Retention
Use of aids to void:__________________________NA___________
History of kidney/ bladder disease: _______________NA___________
Objective:[2]
Urine: Color: __pale yellow___ Odor: __ammonia scent__ Output/hr/shift:_75ml/hr/_750ml/ 10
hrs(shift)
Fluid volume excess
Bladder palpable: Yes No Catheter/Stoma/Ostomy: Yes No Fluid volume deficit
V- Skin integrity Nursing diagnosis
Subjective:[2]
Changes in moles: ______no________ Enlarged nodes: __NA________
History of fever/Infectious diseases: __________________NA________
History of Cancer: ________________________________na________
Objective:[2]
Temperature: ____37 *C____ Lymph nodes enlargement: _______NA__ Hyperthermia
Skin: Moist Dry Warm Cool Pale Pink Jaundiced Hypothermia
Skin turgor: Elastic Firm Fragile Dehydrated Impaired skin integrity
Skin integrity: Intact. Rashes: __NA________ Blisters: _____NA_ Impaired tissue integrity
Surgical incision/scar: ________NA____ Ecchymosis: _NA__________ (Risk for)
Lacerations: ____________NA__________ Ulcerations: ____NA_________ Risk for infection
Pressure sores: _______________NA________________________________
COGNITIVE /PERCEPTUAL
Subjective:[2]
History of: Fainting/ Syncope:__once when running for 1.5 hours_ Dizziness:_4 times in past 2months
and it lasted for 5-10 min
Headaches: Location____NA_____ Frequency ___NA____________
Stroke ________NA_________ Seizures ______NA_________ Sensory/perceptual disturbance:
Vision: No problem Deficit: Right Left. Glasses Lenses *Visual
Hearing: No problem Deficit: Right Left. Hearing aid *Auditory
Smell: No problem Deficit:__________________________ *Olfactory
Taste: No problem Deficit:__________________________ *Gustatory
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Objective:[2]
Level of consciousness (check what applies to your patient): Altered thought processes
Alert Drowsy Stuporous Comatose Restless/agitated
Orientation: Time: Yes No. Place: Yes No. Person: Yes No.
Loss of memory: Recent: Yes No. Past: Yes No. Impaired memory
Pupils: Equal size: Yes No. If no, describe:_________________
Pupil reaction:
-Direct: Brisk: Rt Lt. Sluggish: Rt Lt. Non reactive: Rt Lt.
-Consensual: Brisk: Rt Lt. Sluggish: Rt Lt. Non reactive: Rt Lt.
Facial droop: Rt Lt. Gag reflex: Present Absent
Handgrasp: Rt: ______fast_________ Lt: ___fast__________
Deep tendon reflexes:__________+2_____________________ Nursing Diagnosis
Verbal response: Clear Slurred Unintelligible Aphasic Impaired verbal communication
Gait Disturbance  Yes  No Paralysis (Describe)___NA___________________
FEELING
A-Pain
Subjective: [2] Pain: Yes No. Pain
Onset: ____6 months ago(13/02/2020)____Location: __chest area_____ Radiation: __no______
Intensity (1-10): _6____ Quality: _dull______ Frequency: twice a day
(morning & night)
Duration: 1 hr Associated with: ___fatigue and shortness of breath_________________
Aggravated by: ____NA_______ Alleviated by: __taking one 500mg pill of painkillers_________
Objective:[2]
Facial grimacing: Yes No. Guarding affected area: Yes No.
Emotional response to pain: Crying Withdrawn Angry
B-Psycho-Socio-Cultural
Emotional Integrity:
Subjective:[1]
Recent stressful life events other than illness: Yes No.
If yes, describe: mother and father dead in an accident
How do you usually manage stress? ____eat junk food
Objective:[1]
Emotional status (check those that apply): Anxiety
Calm Cooperative Anxious Angry Withdrawn Fear
Combative Irritable Euphoric Other very sad and miserable___ Grieving
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Associated physical manifestations: _teary eyes but never cries, tries not to talk much
Impaired social interaction
Role:[1]
Role within family: Breadwinner Caregiver Other__________ Altered role performance
How does your illness affect your:
Family:_brother starting to be depressed like him_________
Job__took 2warnings because of taking a lot of days off with no valid reason( he feels down at
some days so decides not to go to work)___

Valuing:[1]
Does illness/hospitalization interfere with any of the following:
1. Religious practices: Yes No. _________________________
2. Cultural practices: Yes No. _________________________
3. Family traditions: Yes No. _____stop doing all family traditions
SEXUALITY/REPRODUCTION Nursing Diagnosis
Female
Subjective:[1]
Age at menarche: ____ Length of cycle: _____ Duration: ________
Last menstrual period: _______________ Menopause: Yes No.
Vaginal discharge: __________ Bleeding between periods: : Yes No. Altered sexuality patterns
Practices breast self-examination: ______ Last pap smear: _________
History of STD: __________________________________________
Sexual concerns/problems:___________________________________
Objective:[1]
Breast examination: ______________________________________
Vaginal warts/lesions: _____________________________________
Male [2]
Penile discharge: ____clear_______ Prostate disorder: ________NA_____
Practices self-examination: Breast: __________ Testicles: __Yes, once a year______
Last prostate exam: _____None________
History of STD:___none_____________________
Sexual concerns/problems: _____none_______________________
KNOWING [1]
Familial history (Specify which relative has the disease):
Anemia/blood dyscrasias _____NA____ Peripheral vascular ____Na________
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Cancer ____________________NA___Kidney disease __________NA_____

Diabetes ________NA______________ Stroke _________________NA_____
Heart disease _____NA______________Tuberculosis _______________NA__
Hypertension ______NA_____________ Other: ______________________

Knowledge about current illness: lack knowledge about depression and doesn't know that it can be
treated
Knowledge deficit

Knowledge about current medications/treatments: __doesn't take medications but willing to learn and
start taking
Expectations of therapy: treat his low heart rate (bradycardia) & start treating his depression.
Requesting information concerning: depression _____________________________

List the nursing diagnoses identified to your client in priority order:

1. Ineffective breathing patterns
2. Altered comfort related to chest pain
3. Pain
4. Altered nutrition less than body requirement
5. Fatigue
6. Sleep pattern
7. Grieving
8. Risk for activity intolerance
9. Impaired social interaction
10. Altered role performance
11. Knowledge deficit
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SN/ND/er/HD, June 2010